Stroke: Transient Ischaemic Attack

Question 1

Definition

Answer 1

NOT A STROKE
Sudden onset of focal neurological deficit due to temporary focal cerebral ischaemia without acute infarction
< 24 hours = typically 5-15 mins

Question 2

Epidemiology

Answer 2

Males
Black people
Increasing age

Question 3

Risk factors

Answer 3

IHD
Hypertension
Smoking
Diabetes
Hypercholesterolaemia
Atrial fibrillation
Carotid stenosis
Obesity/ Hypercholesterolaemia
VSD

Question 4

Location

Answer 4

90% = ICA (anterior circulation)
10% = Vertebral (posterior)

Question 5

Symptoms

Answer 5

CAROTID -
Facial weakness
Limb weakness
Slurred speech
Amaurosis fugax
- Temporal occlusion of retinal artery/ hypoxia
- Unilateral
- “Like curtains descending”
VERTEBROBASILLAR - VerteBrobasiLlar
Vomiting
Loss of balance
Bilateral limb weakness

Question 6

Signs

Answer 6

CAROTID -
Focal neurology
Irregular pulse (AF)
Carotid bruit - carotid artery stenosis
HTN
VERTEBROBASILLAR -
Diplopia
Vertigo
Ataxia

Question 7

Diagnosis

Answer 7

Exclude differentials:
- Hypoglycaemia
- Intracranial haemorrhage: All patients on anticoagulants or with similar risk factors should be admitted for urgent imaging (NCCT head)
- CT should not be done unless clinical suspicion of haemorrhage
- Carotid artery stenosis embolism: Carotid duplex USS performed within 24 hours of assessment in patients considered for carotid intervention

MRI (including diffusion-weighted and blood-sensitive sequences): Preferred to determine the territory of ischaemia or to detect haemorrhage or alternative pathologies.

Question 8

Assessment and referral

Answer 8

Patients with suspected TIA should be:
- given 300mg of aspirin
- assessed urgently within 24 hours by stroke specialist clinician

If a patient presents more than 7 days ago they should be seen by a stroke specialist clinician as soon as possible within 7 days.

Question 9

Treatment

Answer 9

FIRST LINE =
- Aspirin: Initial 300mg followed by 75mg OD for 21 days
- Clopidogrel: Initial dose 300mg followed by 75mg OD (long term mono therapy)

• Lipid modification: Atorvastatin 80mg
• Patients with A.fib should be anticoagulated as soon as ICH has been excluded.
• Carotid endartectomy recommended if patient has suffering stroke or TIA in carotid territory and not severely disabled. Only considered if stenosis > 50% stenosis according to North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria

Question 10

When not to offer aspirin in these circumstances

Answer 10

• Bleeding disorder or taking an anticoagulant: needs immediate admission and assessment
• Taking low-dose aspirin regularly: continue the current dose and arrange a specialist review
• Aspirin is contraindicated: needs specialist advice